Name of Applicant or Representative *:

Email:

Phone *:

Address *:

City *:

State *:

Zip *:

Name of Organization Represented (if applicable):

IRS Tax ID Number (if applicable):

Title/Subject/Purpose of Activity *:

Number of Individuals Participating in this Activity *:

Category of Nonprofit Activity (check applicable):

Government

Private - County-Based Nonprofit Organization

Private - County Employee

Private - County Resident

Requested Date and Time of Activity:

First Choice *: Date: From: To:

Second Choice: Date: From: To:

No helium-filled balloons are allowed in the Community Room.

Will Advertisements/Brochures be distributed? Yes No
If Yes, fax a copy to the Hunter Mill District Office at 703-471-6847.

Will Food/Drinks be served? * Yes No
If Yes, describe:

Will a fee be charged to participants? * Yes No
If Yes, describe:

As with all correspondence received by the Board of Supervisors, the content of your message, including your name, address, phone numbers and E-Mail address, are subject to disclosure under the provisions of the Virginia Freedom of Information Act, and if requested must be provided.